Fill out this form below so we can better assist you with:

   •Updates to your billing and insurance information.
   •Questions concerning your Dynacare invoice.
   •Insurance questions or concerns.

After you complete this form, your information will be sent to the Dynacare Milwaukee Billing Department. If we have any questions, we will contact you. Please feel free to add more information in the "Comments and Questions" box (step 6) regarding your account.

Please provide the information from your bill * = required Accession/Account Number: (This is the account number on your bill) * Patient First Name: (As it appears on your insurance card) * Patient Last Name: * Patient Address: * City: * State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming * Zip Code: * Patient Date of Birth: * Patient Gender: ---- Male Female * Patient Telephone Number: Patient Email Address:     Tell us about the Doctor you visited Doctor's First Name: Doctor's Last Name: Doctor's Address: Doctor's City: Doctor's State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Doctor's Zip:     Your Insurance Information Patient's relationship to policy holder: Self Spouse Child Other Responsible Party First Name: (if different than patient name) Responsible Party Last Name: (if different than patient name) Insurance Company Name: * Insurance Company Address: Insurance Company City: Insurance Company State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Insurance Company Zip Code: Insurance Company Telephone: Policy Holder SSN#: Insurance ID Number: Medicare Number: Medicaid Number: Insured Employer: Insurance/Group Number: Additional Comments: